Monday, May 23, 2016

Several years ago, after leaving my scientific position at AHRQ and feeling that my patient care skills had become rusty, I took a part-time job as a staff physician at a rapidly growing chain of urgent care centers. I thought that urgent care's relatively limited scope of practice would ease my transition back into the clinic, and though the pace was often intense, I quickly became comfortable sewing up lacerations, draining abscesses, diagnosing fractures, and fishing various objects out of ears and noses. All in all, it was a rewarding experience: my physician colleagues were friendly and experienced, the support staff skilled and professional, and since we stayed open from from 7 AM to 10 PM every day of the year, our walk-in patients were generally grateful to be seen.

After about a year of this work, I decided to return to academic medicine. During my interview, I mentioned to the then-Department Chair that I had been working in urgent care. He visibly grimaced, then said something about urgent care centers "skimming the cream" of primary care and leaving full-service family practices with the more complex and less lucrative types of visits. And I couldn't really disagree. If there's one axiom at the heart of family medicine, it's the importance of continuity of care - meaning, whether you feel sick or well, seeing a doctor who knows you will make it more likely you will get the care you need. A systematic review in the Journal of Family Practice and a more recent review in the Journal of Evaluation in Clinical Practice both concluded that increased continuity was associated with higher quality care, better outcomes, and higher patient satisfaction.

The problem with prioritizing continuity of care is ensuring access. My current practice is open until 8 PM two evenings per week and, until recently, we also saw patients on Saturday mornings. But none of us really like to work on Saturdays, and we recently learned that of all the primary care practices in our health system, we are the only ones who ever even try be open on that day. Further, the nature of an academic practice is that my colleagues and I are only each at the office a day or two per week, further limiting the ability of patients to see the same doctor every time. Can continuity of care be said to have the same value if it's only with the same office, rather than the same person? It's a question that needs answering, as a study from the Robert Graham Center found that an increasing proportion of Americans identify an office or facility, rather than an individual clinician, as their usual source of health care.

Finally, retail health clinics (think CVS's Minute Clinics), like urgent care centers, have emerged and prospered as a response to deficiencies in primary care access, but handle a more limited range of acute problems and are staffed by nurse practitioners rather than physicians. On one hand, retail clinics may disrupt continuity of care, but on certain measures of quality, such as antibiotic prescribing for respiratory infections, they are more likely to adhere to national guidelines. And even a respected health policy researcher such as Dr. Aaron E. Carroll, a professor of pediatrics at Indiana University, admits that he would rather take his child to a retail clinic for a sore throat than deal with the hassle of getting a same-day appointment with their usual physician. So much for continuity of care and the patient-centered medical home that physician groups have been advocating for the past decade as the solution to excessive health spending and mediocre outcomes! Or can these concepts coexist with the convenience of urgent and retail health care?

Tuesday, May 17, 2016

On Thursday, May 19th, the World Organization of Family Doctors (WONCA) will celebrate World Family Doctor Day, a day that since 2010 has highlighted the roles and contributions of family physicians in health and health care systems worldwide. The term "global health" has evolved from being used primarily to describe volunteer medical work in developing countries to a broader concept that recognizes the easy transmission of infectious diseases across continents and international boundaries (e.g., outbreaks of Ebola and Zika virus) and the presence of international refugee and immigrant populations with specific medical needs in the "backyards" of the United States. In a 2015 American Family Physician editorial, my Georgetown and Medscape Family Medicine colleague Dr. Ranit Mishori and Dr. Jessica Evert explained why incorporating global health experiences into Family Medicine training and practice "matters now more than ever":Global health exposure internationally and locally helps develop a broader health system perspective, greater attention to the social determinants of health, and an understanding of population health concepts. Engaging in global health can bolster cross-cultural competencies, along with the desire to work in resource-poor settings. Additionally, it can strengthen skills and passion to care for underserved populations domestically. A few studies have even suggested an association between global health experiences and an increased interest in primary care.

Monday, May 9, 2016

For me, the words "palliative care" bring to mind a picture of a patient suffering from incurable cancer, perhaps one that has spread to the bone or brain. Avoiding death from cancer, even via screening tests or therapies that increase the risk of death from other causes (thus providing no overall health benefit) is a reason that physicians sometimes cite for continuing cancer screening long beyond what guidelines recommend. Clinicians may be less likely to view patients with non-cancer diagnoses, such as end-stage heart disease, as potentially eligible for palliative or hospice care, Dr. Marc Kaprow wrote in a 2010 editorial in American Family Physician. In a 2013 editorial, Drs. Rebecca McAteer and Caroline Wellbery encouraged readers to take a broader view of this underutilized service:

Palliative care improves the quality of life for patients with a life-threatening illness and for their families. It aims to relieve suffering by identifying, assessing, and treating pain and other physical, psychosocial, and spiritual problems. Palliative care can be provided whether an illness is potentially curable, chronic, or life-threatening; is appropriate for patients with noncancer diagnoses; and can be administered in conjunction with curative-aimed therapies at any stage of the illness.

Heart failure provides a good example of a condition that benefits from palliative care, especially in its advanced stages. Although increasing resources have been devoted to preventing heart failure readmissions, palliative care interventions remain poorly integrated despite the downward disease trajectory that nearly all patients experience. A 2009 review in Circulation concluded that palliative care improved patient and family satisfaction; facilitated communication between patients and health professionals; increased access to community support services; and was associated with a greater likelihood of patients dying at home. It also produced significant cost savings from fewer invasive end-of-life interventions and hospitalizations.

A more recent review in BMJ summarized the past 5 years of medical literature on palliative care in heart failure. Common symptoms that palliative care can address effectively include pain, breathlessness, fatigue, and depression. Older adults with heart failure have 4-5 comorbidities on average and are more likely to experience frailty than the general population. As rising numbers of these patients receive implanted cardioverter defibrillators and left ventricular assist devices, device deactivation is rarely discussed even when patients become critically ill. The American Heart Association encourages scheduling an "annual heart failure review" to provide time for shared decision-making around these topics and to assure that treatment intensity and future plans are aligned with patients' goals and preferences.

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About Me

I am a board-certified Family Physician and Public Health professional practicing in the Washington, DC area. I am also Deputy Editor of the journal American Family Physician and teach family and preventive medicine and population health at Georgetown University School of Medicine, Uniformed Services University of the Health Sciences, and Johns Hopkins University Bloomberg School of Public Health.
I am paid to provide independent editorial and medical consulting services to the American Academy of Family Physicians, John Wiley & Sons, BHS, and WebMD. However, the content of this blog reflects my personal views only, and does not represent the views of any academic institution, publisher, BHS, or the AAFP.